Provider Demographics
NPI:1053962043
Name:DAVIS, COOPER EVIN
Entity type:Individual
Prefix:
First Name:COOPER
Middle Name:EVIN
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 GROVE ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-2236
Mailing Address - Country:US
Mailing Address - Phone:262-501-7590
Mailing Address - Fax:
Practice Address - Street 1:616 GROVE ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-2236
Practice Address - Country:US
Practice Address - Phone:262-501-7590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-22
Last Update Date:2019-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker